Grievance And Appeals Coordinator Resume Example

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Jessica Claire
, , 100 Montgomery St. 10th Floor (555) 432-1000,

Self-Driven, Flexible, Innovated; 10 years experience in Healthcare and customer service; self-motivated with excellent interpersonal skills; excellent time management; detail oriented and well organized; Keen on picking up on new materials; exceptional ability to adapt quickly to changing situations while working under pressure; eager to learn; Strong willingness to grow and work well with others

04/2017 to 01/2020 Grievance and Appeals Coordinator Change Healthcare | Coulters, PA,
  • Investigated and resolve Medicare Part C and Part D, Medical member grievances, gathered supporting documentation from internal departments, contracted Provider Organizations (PO), and non-contracted entities; respond orally or generate written communications, efficiently closing cases within designated regulatory time requirements
  • Demonstrated and successfully follow procedures ensuring efficient handling of part D coverage determinations appeals are not untimely for the organization
  • Responsible for and part D coverage determinations or appeals, thoroughly, Part D Appeals and Grievances`; accuracy, thoroughness and orderliness.
  • Served as subject matter expert for Part D Appeals and Part D Grievances as a liaison between the SCAN Pharmacy Team
  • Stayed current and up to date on regulatory changes to the Parts C and D Enrollee Grievance, Organization/Coverage Determinations and Appeals Guidance;
  • Broadened professional development to strength knowledge and skills, providing higher member satisfaction.
05/2016 to 08/2016 Grievances/Appeals Analyst M/I Homes | Houston, TX,
  • Respond in writing to members, providers and Health Plan partners, making informed judgements on the proper application of member’s dental plan benefits,
  • Performed accurate adjudication of claims and referrals and other potential issues by conducting timely, thorough investigations of assigned grievance and appeals cases.
  • Execute all required administrative intake activities accurately and in accordance with established internal, contractual and regulatory deadlines.
  • Possess, or have the ability to easily adapt to new computer systems
  • And programs.
  • Create and maintain files for regulatory and client review, and
  • Internal reference.
  • Demonstrates team-oriented attitude by following directions from
  • Supervisor, interacting well with co-
  • Workers, accepting and following work rules and procedures, complying
  • With corporate policies, goals and
  • Objectives, accepting constructive feedback and exhibiting initiative
  • And accountability for your work.
  • Interface with other internal and external entities, ensuring a
  • Positive and professional relationship.
  • Adapt easily to change and shifting priorities.
  • Performs other duties as assigned or determined appropriate by management.
09/2015 to 03/2017 Appeals Pharmacy Technician Coordinator UnitedHealthGroup Inc, OptumRX | City, STATE,
  • Efficiently Review, thoroughly research medication request submitted by members and providers enrolled in Medicare Part D and Commercial Plan , identify and determine denial reason
  • Effectively review applicable pharmacy benefit coverage for member, relevant clinical criteria, and the utilization review specification standards
  • Document final determination of appeals or grievance using the appropriate templates and process response letters.
  • Demonstrated excellent collaboration working with other members of the team as well as Consult with Clinical Pharmacist Appeal Reviewers
  • Focused and Ensured high quality and clinically appropriate medication appeal reviews, demonstrating and communicated in a timely, appropriate manner
  • Identify and obtain all additional information (relevant medical records, contract language and process/procedures regulatory information for commercial plans) needed to make an appropriate determination of the medication appeal.

04/2014 to 05/2015 Prior Authorization Technician | City, STATE,
  • Using established criteria and guidelines, processes prior authorization requests made by providers and members for medications not inherently covered on a member's prescription drug plan.
  • Answer prior authorization inquiry calls (up to 100 calls daily) or/and faxes as well as research and resolve formulary and benefit issues using the appropriate reference material.
  • Effecto contactracted pharmacies through Pharmacy Help Resolve issues efficiently to and complaints in a timely and efficient manner.
02/2012 to 02/2014 Pharmacy Technician NA | City, STATE,
  • Assign Pharmacy Technican Specific Bays for Outdated/Damages.
  • Led and successfully served as subject matter expert and point of contact Pharmacy Staff for New System enhancement for Pharmacy Staff in district (18 Pharmacy Stores,
  • Improved drug inventory management procedures to reduce waste and eliminate backorders or overstock.
  • Assisted pharmacist with clearing high volume of problem prescriptions and customer questions to maintain optimal team efficiency.
  • Managed inventories, rotated stock, removed expired or damaged drug products and resolved discrepancies in drug counts.
  • Trained 15 new technicians to provide excellent customer service which resulted in 35 % higher customer satisfaction scores.
  • Participated in pharmacy Store Acquisitions and Pharmacy medication inventory audits.
  • Eliminated third-party rejection claims through working with pharmacy insurance plans.
  • Checked accuracy and productivity in performance of Pharmacy Technician's operational activities to maintain active pace of pharmacy.
11/2009 to 08/2011 Sales Associate CVS Pharmacy INC | City, STATE,
  • Surpassed daily sales goals by 30% by cross-selling womens shoes and promoting additional products.
  • Assisted customers by finding needed shoe items and checking inventory for items at other locations.
  • Recommended optimal merchandise based on customer needs and desires.
  • Met or exceeded upselling, donation and credit card sign-up targets on consistent basis by leveraging excellent communication and interpersonal strengths.
  • Used cash register system to ring up customer purchases, process payments and issue receipts.
  • Coverage Determination and Organization Determination Procedures
  • Medical terminology
  • Inventory Management Procedures
  • Medicare Knowledge
  • Pharmacy Medication Claims Process
  • Team leadership
  • Pharmacy Operations
  • Workflow Optimization
  • Verbal/written communication
  • Microsoft Office
  • Time management
Education and Training
Expected in 2012 ASHP-Accredited Pharmacy Technician Program | American Career College, , GPA:
Expected in 2009 High School Diploma | Westminster High School, Westminster, CA GPA:
  • Certified by the Pharmacy Technician Certification Board (PTCB): Certification Number: 10042737
Activities and Honors

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Resume Overview

School Attended
  • American Career College
  • Westminster High School
Job Titles Held:
  • Grievance and Appeals Coordinator
  • Grievances/Appeals Analyst
  • Appeals Pharmacy Technician Coordinator
  • Prior Authorization Technician
  • Pharmacy Technician
  • Sales Associate
  • ASHP-Accredited Pharmacy Technician Program
  • High School Diploma